While it does take some time to transition away from the standard American diet, your body, mind, and spirit will certainly thank you.  Even after one day of whole-food based meals, you may feel lighter and more energized. Hopefully it will continue to inspire you and those around you to strive for the highest quality food.  Quite honestly, your health and wellness depend on it. When I’m asked the question of whether it’s really necessary to buy organic foods, I often refer to the Environmental Working Group.  They have compiled a list of the “Dirty Dozen” or produce with the highest amounts of pesticides.  These are the ones I would certainly aim for organic and include:  apples, celery, strawberries, peaches, spinach, nectarines, grapes, sweet bell peppers, potatoes, blueberries, lettuce, and kale/collard greens.  But generally speaking, shopping locally and seasonally will usually be your best option.  So start now by incorporating a few new whole foods into your diet every week until you feel comfortable and see how much better you start to feel!

Herbals are often composed of many active healing constituents, so it’s not easy to trace reactions to one ingredient.  Many times the media or even medical experts may paint a negative picture of these products.  Be careful of reports that make conclusions based on flawed or incomplete scientific research, base claims of toxicity on single parts of herbs (ignoring the safer and more commonly used part of the herb), or use cases of overdose or misuse.  When helping patients select an herbal or dietary supplement, look for reputable companies that source quality raw materials and adhere to good manufacturing processes.

Americans got their first taste of canola oil in 1986 and have since been bombarded with the many purported health benefits. A few years ago, the FDA gave the O.K. for the health-labeling claim that canola oil may reduce the risk of heart disease. This comes from the fact that it has less saturated fat compared to most other oils. Canola oil has omega-3 polyunsaturated fat and a high amount of monounsaturated fat. But I still prefer my extra virgin olive oil, especially since there are more studies backing up its health benefits. When I do decide to use canola oil, I choose organic, expeller pressed varieties to reduce my exposure to chemical solvents, pesticides, and genetically modified varieties. Although there are still mixed opinions out there about canola oil, I feel it’s a good option for cooking and baking in moderation.

When it comes to habits (both good and bad), research has shown that it takes 21 days to establish a habit.  If change were easy, all your patients would be whipping up a salad at home instead of heading towards the McDonald’s drive-through. As their health coach, it is helpful to remind them that it takes time to retrain the mind and body.  You can support them during this transition by helping them set small weekly goals and checking in with them regularly on their progress.

There is definitely something to be said about having a positive attitude.  Some of the health benefits from positive thinking include living longer, lower rates of depression, improved resistance to the common cold, decreased risk of death from cardiovascular disease, and better coping skills during stress.  You can help your patients battle their negative attitude by simply suggesting alternative language that is more positive.  An example would be if a patient says, “I’m so unhealthy” then you can suggest they say something like, “I’m taking steps everyday to improve my health”.

It’s no surprise why Weight Watchers has been such a successful program through the years. A 2006 study published in the British Medical Journal found that weekly support meetings help people comply with weight-loss plans longer than those using unsupported programs.  The lead study author also notes that group support reduces the amount of weight people gain back after the first six months of dieting. When patients partner with us to be their health coach, they are counting on us to keep them moving forward.  One of the most effective things we can do for them (in addition to providing education) is give them that positive reinforcement to help them overcome their personal barriers.

Believe me…I was ready to give up after just a few months of meager success.  It reminds me of a common expression that long distance runners use:  ‘hitting the wall.’  If you’re a runner like myself, you know that almost every runner experiences a time during their run in which they become tired and are ready to give up.  However, runners who work through this time eventually feel much more rejuvenated and are able to complete the course.  This same principle can be easily applied to pharmacists attempting to launch the Sweet Spot program in their store(s).  Pharmacists who push through the time of ‘hitting the wall’ usually experience great success down the line.

I have several thoughts on why pharmacies working through early struggles tend to be more successful, but I believe it ultimately boils down to patients and physicians seeing consistency in the program.  Physicians, for example, weren’t willing to forward patients to our class until they saw consistency in our program.  One physician remarked, ‘I just assumed you were having a few ‘Diabetes Days,’ but I realized you actually have a great service you can provide to my diabetes patients on a consistent basis.

If you’re currently ‘hitting the wall,’ be encouraged!  Keep your classes consistent.  Let your area physicians know you don’t plan on quitting any time soon.  If you’re ‘hitting the wall,’ be sure let us know…we’re full of ideas to break through the wall!’

David D. Pope, PharmD, CDE

Editor-in-Chief, CreativePharmacist.com

David can be contacted at david@CreativePharmacist.com, or 706.210.9087

Depression is associated with an increased risk for coronary heart disease in healthy patients and cardiac morbidity and mortality in patients with coronary heart disease.   However, little research has been done to determine the role antidepressants play in this risk.    This study was conducted among patients with a diagnosis of depression, to determine the long term risk of myocardial infarction (MI) in patients who have taken antidepressants compared with those who have not.

METHODS:  This study was conducted retrospectively, among more than 93,000 patients of the Veterans Affairs (VA) who were diagnosed with depression between October 1999 and October 2000.  According to VA guidelines, at least 12 weeks of antidepressant therapy should be given for a new episode of depression.  Of the patients identified, 78.7% received at least 12 weeks of antidepressants, 12.9% received 1 to 11 weeks of antidepressants, and 8.4% received no antidepressant therapy.  Those patients who received at least 12 weeks of antidepressant therapy were the treatment cohort, while those who received less than 12 weeks of antidepressant therapy, or no therapy, were the control.  The patients identified were then tracked from October 2000 through September 2007 for MI and cardiac death.  The study excluded patients who already had a diagnosis of heart disease or cerebrovascular disease.  Also, patients with psychotic and bipolar disorders were excluded, as well as those with a diagnosis of dysthymia.   The study was controlled for severity of depression as well as for other risk factors for MI, such as hypertension, diabetes, obesity, and hyperlipidemia.  The study was also controlled for individual antidepressants and classes.

RESULTS:  The average age of patients in this study was 51, and the population was 86% male.  78.8% of the population was treated with an antidepressant, while the remaining 21.2% had either never taken an antidepressant or had taken one for less than 12 weeks.  In this study, significantly fewer patients in the antidepressant treatment group suffered an MI or death, than in the control group.  Accordingly, in each class of antidepressants and in each individual drug, the same conclusion held true, that there were fewer MIs than the control group.

DISCUSSION:  Among VA patients with a diagnosis of depression, those who used antidepressant drug therapy for at least 12 weeks had significantly fewer MIs and all-cause mortality than those who did not.  While earlier evidence showed that depression is a risk factor for heart disease, this study suggests that antidepressants reverses that risk and provide some protection.   The mechanism of this protection is unknown.  The protective mechanism of SSRIs is generally attributed to its effects on platelet aggregation.  Tricyclic antidepressants (TCAs) have been shown in previous studies to have cardio-toxic effects and contribute to arrhythmias.  This study showed no cardiac ill-effects associated with TCAs, and showed the same protective effects that the other antidepressants have.  Compliance in drug therapy may be a confounding factor in this study.  Patients willing to take antidepressants and continuing taking them for at least 12 weeks may also be more compliant with cardiac drug therapy and instructions from their healthcare providers.   This alone may explain the link between antidepressant drug therapy and cardio-protection.  However, the link this study found should not be ignored and should fuel further study into the cardio effects of depression and the cardio-protective properties of antidepressants.₁

As with any of our Healthy Heart patients, diet, appropriate cardiovascular pharmacotherapy, and exercise should be monitored and/or recommended.  As we all know, exercise is extremely beneficial in elevating mood.  However, now when we have to rely on antidepressant medication we can be more confident that we are not increasing our patient’s cardiovascular risk.  We actually might be decreasing their chances of having a heart attack……that should give them a reason to smile!

₁ “Antidepressant Drug Compliance:  Reduced Risk of MI and Mortality in Depressed Patients.”  The American Journal of Medicine. Vol. 124. Issue 4. April 2011.  pgs 318-324.

Here’s the link to the article: http://www.nytimes.com/2010/08/14/health/14pharmacist.html?_r=1

I explained to the mother that Medicaid would not cover the morphine and that I had concerns that the dosage interval seemed a bit long compared to the duration of action of that drug, potentially putting her at risk for breakthrough pseudo-addiction reactions.  In search of more information, I asked for any other paperwork she may have received from Vanderbilt; after looking over the discharge summary, I noticed that the nurse recorded “MS Contin” for the morphine taper-down regimen.  This made much more sense to me, so I called Vanderbilt for clarification.  A plastic surgery resident called back and said with some trepidation that she didn’t think that MS Contin could be taken Q8h and that the nurse practitioner who wrote the prescriptions was extremely cautious and thorough.  While she did understand my concerns, she said that the prescription should be for the MS IR and asked that I fill the prescription with that medication.  I reluctantly agreed and hung up the phone.  After talking to the mother a bit longer, I decided that the discharge nurse was right and filled the prescription for MS Contin.  I explained my leap of faith to the patient, who agreed with my logic and, while we both agreed that Vanderbilt physicians, even residents, are some of the best in the country, she said that she too believed that the prescription was supposed to be for MS Contin based upon previous hospital discharges.

I gave her my business card and asked that she give it to the physician on Monday at her daughter’s follow-up appointment so that nobody but me could take the blame for being wrong in my judgment call.  Thankful for my time, she left.  I called the surgery department on Monday morning and left a rather long message about the incident and that, if I was wrong, it was in the interest of the patient that I filled it incorrectly and not because I was negligent.  Shortly thereafter, I received a call back from the nurse who not only told me I was right, but thanked me for taking care of their patient.  While I can’t say that I expected to hear that news, I was quite thankful that it came my way nonetheless.

I’m sure most of you think that I am crazy to have handled that situation the way I did.  I can imagine that, if given the situation as a hypothetical scenario even earlier that day, I would have made different choices.  However, when faced with a mother who was desperate to take care of her daughter and a girl who was having to go through more than most her age, I chose patient care over the letter of the law.

All of us face this conflict daily, although rarely to such an extreme.  Most of the time this choice is rather benign and may simply get you in trouble on a third-party audit: adding another refill to a maintenance medication before getting the prescriber’s authorization, adjudicating and dispensing for a bit more liquid than the prescription calls for to account for loss, or not getting a DEA number for a narcotic prescription left on the voicemail when you know the prescriber’s voice and prescribing habits. While nobody can argue that this is the legally correct thing to do, those of us who regularly do such things do so because we are genuinely interested in taking care of the patient.  To us, the law is primarily meant to protect public safety, and if we can justify our actions through providing the best patient care, are we not following the intent of the law even if we are not following the letter of the law?  This is certainly the stance that most Boards of Pharmacy would take.  In fact, the Executive Director of Tennessee’s Board typically answers each question I make to him by telling me to “just take care of the patient.”  While he may not have handled my aforementioned situation in quite the same way as I did, I daresay he’d not hold my decision against me.

Perhaps the most important document to consider in all of this is the Oath of the Pharmacist.  In it, different aspects of patient care and public health are covered very eloquently and in great detail long before the word “legal” is even mentioned; even then, it is mentioned last after the words “moral” and “ethical” when describing a pharmacist’s conduct.  To me, this implies that our professional duty to take care of our patients is far more important than making sure we follow the law like a police officer.  I am certainly not saying that we should abandon the laws altogether, but when we consider why the laws are in place—the protection of patient and public safety—we must evaluate each situation in its entirety and determine which road would bring about both the intent of the law and the intent of our Oath, which almost always agree with one another.

Let me conclude by asking you to consider how you would have handled this particular situation.  Would you have done the same as I did?  How have you handled similar situations?